Complaint Investigation Report

This is an amended report. Correct visit date 5/18/2022.

When R1 becomes physically aggressive with staff, the SNCP indicates staff will evade and use the least restrictive Crisis Prevention Intervention (CPI) method to assist R1. Multiple interviews with staff revealed some of the techniques used during this incident did not reflect CPI interventions, descriptions of the intervention as a single person hold, and resembling MMA (Mixed Martial Arts) techniques. Staff interviews, and a review of records confirmed the facility has conducted an incident debriefing, and staff have been retrained in CPI methods.

It was alleged the licensee did not meet reporting requirements. An interview with an outside source confirmed an external review of the incident, including the debriefing process, was conducted, and revealed the facility did not meet reporting requirements. Review of the incident debriefing documents and an interview with staff confirmed the reporting requirements were not met.

Based on review of records and interviews, there is a preponderance of evidence to prove the alleged violations occurred, therefore, the allegations are Substantiated. These deficiencies are documented in an LIC 9099D

An exit interview was conducted with Administrator, Ann Marie Stanton, to whom a copy of this report and Licensee's Rights (LIC 9058 01/16) were provided to.